Mohamed Rahman · Prevention of Future Deaths report

On the 19th February 2018, I commenced an investigation into the death of Mohamed Rahman. The investigation concluded at the end of the Inquest on the 6th June 2018.

The mother of baby Mohamed Rahman was referred to St Mary's Hospital Fetal Medicine Unit due to the diagnosis of a spina bifida defect on the routine fetal scan. The parents were informed to attend for an elective feticide procedure on the 16th February 2018. The procedure went smoothly and without complications with the Obstetrician noting an immediately reactive fetal heart and the umbilical cord via the umbilical cord was then clamped. Following the administration of potassium chloride via the umbilical cord and the seconds of watching the fetal heart on the ultrasound, a lack of movement was noted to confirm fetal asystole and so the procedure was completed. Both mother and foetus were discharged home on the morning following which occurred in the Royal Bolton Hospital for induction of labour. Baby Mohamed Rahman was born at 01:45 hours on 17th February with spontaneous breathing and movement. Compassionate care was provided prior to the fact of his death being confirmed at 02:48 that day.

1. Mother in particular but also the experienced professionals involved were wholly unprepared for what they witnessed and the feelings of birth when “stunned”, “shocked” and “distressed” were amongst the epithets given in evidence to describe their experience with the birth. The Neonatal team were not present and would not have expected to be present and had to be called urgently to review what had occurred. However well-intentioned - the attempt to reduce the time that a patient waits for the Department of Fetal Medicine scan is time performed by diminishing the scan for confirmation of fetal death contributed to this unintended outcome after termination of the pregnancy.

2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound.

3. Without intending to be prescriptive, it is the opinion that other Departments nationally aware of the tragic sequence of events which took place in Greater Manchester and should consider the implementation of clinical guidance documents and procedures to facilitate unequivocal confirmation of fetal demise.

4. Consideration should also be given to the desirability of a leaflet for parents which fully explains the feticide process using appropriately sensitive and lay terminology.